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HomeMy WebLinkAboutFolio 2024-2026 Permit - CR 7877 CR 7877 - 9/24/2024 CONTRACTOR REGISTRATION 100 West Dania Beach Boulevard * Dania Beach, FL 33004 (954)924-6805*3651,3633 or 3652 Fax(954)922-2687 DANIA BEACH SEA li Eh'E li EOVE li. PLEASE PRINT LEGIBLY Type of Contractor General contractor Company: Name - to 6 /Le— Office Address 10226 Curry Ford rd City/State/Zip Orlando,F1 32825 Office Phone# 4074766212/407-448-5643 Qualifier: Name Paul Donaldson Office Address 10226 Curry Ford rd City/State/Zip Orlando,Fl 32825 Home Phone# 407-448-5643 Owner: Name PAUL DONALDSON Office Address City/State/Zip SAME AS COMPANY Home Phone# PROVIDE PHOTOCOPIES OF THE FOLLOWING DOCUMENTS Qualifier's Driver's License State: Orlando City Business Tax License City: County Business Tax License County: 1802-1240947 State License CGC1534657 Certificate of Competency Certificates of Insurance must show the City of Dania Beach as the Certificate Holder General Liability Expiration Date: 06/22/2025 Workers Compensation Expiration Date: 12/31/2024 I hereby certify that the information contained herein is true and accurate to the best of my knowledge. _l Atedi Qualifier's Signature Date The foregoing instrument was acknowledged before me this 4 day of AUGUST 20 24 By Paul flonalrisnn who is personally known to me or has produced as identification and did(or did not)take an oath 1/144 My Commission Expires: r+�" �'= CRYSTAIPENA : •= MYCOMIAtSS1ON•NH 4189/2 Contractor Registration Rev. •tfti,,.,� ` SOWS:July 9,2027 09/26/2017 Lamm t 1 .114) H Z 0 O C I I 0 _Q W W N ilk tI cn '-'- s'`1 dill fit€ l*'` * Lnf,f- ,--.1 4 .0 N N Q W W _ ' . ; Jiii g 4 O d Mce ,11 1 kik, . ''' ,,, 00 , .37:1) I a) LL. C W 'a" CO . t i i i\ : re - - --i -• < 2 `,::, E OLi- Z _ g '>' t, 1 r VJ w . 1" 't., m o cu 'Q oG 1.... It O „ fit;` , 2L Q - o ' uj • Q E,. Z < _ / „in ,.., 0 tin mom O z ILL 1€ ' 111 ! tt' ? f4r " Lid = O Ca i `DQ a jv At:J...r `W 0 .r I / C./) *i# 4. #* as i4 ifiii•+ > o -{d E Z 0 Q Nw W ZC?o O Lu 0-. u v i L. F v N a tn o W t l' i'llr.' 4, 1 ❑•iCI i ■ t AC€ CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 06/26/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER LUN I AL NAME: Amanda Katulich PGI of West Central Florida,LLC PHONE FAX (A/C,No,Ext): 941-242-9619 (A/C,No): 941-242-9621 608 15th St W E-MAIL ADDRESS: amanda@pgiofwestcentralflorida.com INSURER(S)AFFORDING COVERAGE NAIC# Bradenton FL 34205 INSURER A: Lloyds of London INSURED INSURER B: PJWD Energy LLC INSURER C: 333 N Orange Ave INSURER D: INSURER E: Orlando FL 32801 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSH AUUL EUBK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE I KEN IEU CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 10,000 A CSIXEL00553-00 06/22/2024 06/22/2025 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY C:JMBINEU SINGLE LIMI $ I (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A X EXCESS LIAB CLAIMS-MADE CSIEL01SO4-00 06/22/2024 06/22/2025 AGGREGATE $ 1,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER O I H- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Contractors Pollution Liability CSIXEL00S53-00 06/22/2024 06/22/2025 Limit:$1,000,000/$2,000,000 A Professional Liability CSIXEL00553-00 06/22/2024 06/22/2025 Limit:$1,000,000/$2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) License EC13012687 CGC 1534657 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Dania Beach THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 100 West Dania Beach ACCORDANCE WITH THE POLICY PROVISIONS. Boulevard Dania,FL 33004 UHO SE AUTHORIZED REPRESENTATIVE 4 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ACC)Rc? CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/25/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Todd George Bouchard Insurance for WBS-TG PHONE 866 29 PO Box 6090 (A/C,No.Exec: ( ) 3-3600 ext.623 FAX (A/C,No): Clearwater,FL 33758-6090 E-MAILRSS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Zurich-American Insurance Company 16535 INSURED INSURER B: Workforce Business Services,Inc.Alt.Emp:PJWD Energy LLC 1401 Manatee Ave.West Ste 600 INSURER C: Bradenton,FL 34205-6708 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:23FL0791177708 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DO/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY ,r/N X STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? Y N/A WC 90-00-818-13 12/31/2023 12/31/2024 (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below Paul Donaldson is not included in work comp E.L.DISEASE-POLICY LIMIT $ 1,000,000 coverage. Location Coverage Period: 12/31/2023 12/31/2024 Client# 055260 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) - Coverage is provided for PJWD Energy LLC only those co-employees 333 N Orange Ave,Unit 201 of,but not subcontractors Orlando,FL 32801 to: CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Dania Beach THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 100 West Dania Beach ACCORDANCE WITH THE POLICY PROVISIONS. Boulevard Dania,FL 33004 AUTHORIZED REPRESENTATIVE o ACORD 25(2016/03) The ACORD name and loco are registered ma k sof AC RDORD CORPORATION. All rights reserved. ft tL 47 C< w..,.. m U._ 0 0 ts fig � n • z Rt r, .. x X 0 n =`/ ac to ., g. ; I Im U w --- W 440 x J r. w s3 ., e .4 r ca i c is f V' pq G a O v 43 2 yn11 ] ! 411* 4.;,,,,,,:;-'77.:,•1]..114;117-:.:,. .,,:„..;.'-:4;:::',:::.-!, . 1 -I LU ,„ } �:. �` �; ti , v "° gg 1 _zit-)Qua-.1 v..° o'cr) . . f C �� -141).... --3-1"-i 'T. th- y �° t , { 0 .,mot=' DIVISION OF CORPORATIONS :J t LP O I met.\ I I 0 t.`7 fiat rr Pitt/:`;tutu f Flcwtdri wr/lzste Department of State / Division of Corporations / Search Records / Search by Entity Name / Detail by Entity Name Florida Limited Liability Company PJWD ENERGY LLC Filing Information Document Number L20000338039 FEI/EIN Number 85-3659505 Date Filed 11/03/2020 Effective Date 11/03/2020 State FL Status ACTIVE Last Event LC AMENDMENT Event Date Filed 12/07/2023 Event Effective Date 04/13/2023 Principal Address 333 N ORANGE AVE ORLANDO, FL 32801 Changed: 12/07/2023 Mailing Address 333 N ORANGE AVE ORLANDO, FL 32801 Changed: 12/07/2023 Registered Agent Name&Address Foster's Accounting Services LLC 3270 SUNTREE BLVD STE 101 D MELBOURNE, FL 32940 Name Changed: 04/13/2023 Authorized Person(s)Detail Name&Address Title MGR DONALDSON, PAUL 333 N ORANGE AVE ORLANDO, FL 32801 Annual Reports Report Year Filed Date 2022 04/13/2023 2023 04/13/2023 2024 04/15/2024 Document Imam 04/15/2024--ANNUAL REPORT View image in PDF format 12/07/2023--LC Amendment View image in PDF format 04/13/2023--REINSTATEMENT View image in PDF format 11/03/2020—Florida Limited Liability View image in PDF format Florida Department of State,Di,isfon of Corporations